Nursing Elites

1. A nurse is admitting a client who is in labor and at 38 weeks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2 (HSV-2). Which of the following questions is most appropriate for the nurse to ask the client?

• A. Have your membranes ruptured?
• B. How far apart are your contractions?
• C. Do you have any active lesions?
• D. Are you positive for beta strep?

Correct answer: C

Rationale: The most appropriate question for the nurse to ask the client in this scenario is whether they have any active lesions. Active lesions from HSV-2 during labor increase the risk of neonatal transmission, which would necessitate a cesarean section to prevent the infant from contracting the virus during delivery. Asking about the presence of active lesions is crucial to determine the appropriate management and precautions needed to protect the newborn. Choices A, B, and D are not as pertinent in this situation and do not directly address the potential risk of neonatal transmission of HSV-2.

2. A nurse is assessing a client for signs of hypokalemia. Which of the following findings should the nurse look for?

• A. Muscle weakness
• B. Weight gain
• C. Elevated blood pressure
• D. Increased thirst

Correct answer: A

Rationale: Muscle weakness is a classic sign of hypokalemia. Potassium plays a crucial role in muscle function, and low potassium levels can lead to muscle weakness. Weight gain, elevated blood pressure, and increased thirst are not typically associated with hypokalemia. Weight gain can be seen in conditions like fluid retention, elevated blood pressure can result from various causes, and increased thirst may be a symptom of conditions like diabetes.

3. A client with chronic renal failure needs dietary instructions. Which of the following should the nurse provide?

• A. Increase calcium intake
• B. Provide a diet high in potassium
• C. Restrict protein intake
• D. Increase fluid intake

Correct answer: C

Rationale: The correct answer is to instruct the client to restrict protein intake. In chronic renal failure, the kidneys are unable to effectively filter waste products, so limiting protein helps reduce the buildup of waste in the body. Increasing calcium intake (Choice A) is not typically necessary unless there is a specific deficiency. Providing a diet high in potassium (Choice B) is contraindicated as potassium levels need to be monitored and controlled in renal failure. Increasing fluid intake (Choice D) may be necessary depending on the individual's condition, but restricting protein intake is a more critical dietary instruction for clients with chronic renal failure.

4. When teaching a client about the correct use of a cane, what should the nurse include?

• A. Ensure the cane has a rubber cap
• B. Hold the cane on the stronger side
• C. Flex the elbow slightly when using the cane
• D. Use a quad cane for increased support

Correct answer: B

Rationale: When using a cane, it should be held on the stronger side to provide optimal support and stability. This positioning allows the cane to bear weight effectively and helps in improving balance. Option A about ensuring the cane has a rubber cap is important for preventing slipping but is not directly related to the correct use of the cane. Option C, flexing the elbow slightly, is a general guideline and may vary depending on the individual's height and the type of cane being used. Option D suggesting the use of a quad cane for increased support is not necessary if a standard cane is sufficient for the client's needs.

5. A nurse is receiving a report on four clients. Which of the following clients should the nurse assess first?

• A. A client who has an ileal conduit and mucus in the pouch
• B. Client with arteriovenous fistula with additional vibration palpated
• C. A client with chronic kidney disease and cloudy dialysate outflow
• D. A client with transurethral resection of the prostate with red-tinged urine

Correct answer: C

Rationale: The nurse should assess the client with chronic kidney disease and cloudy dialysate outflow first because cloudy dialysate outflow suggests peritonitis, a serious complication of peritoneal dialysis that requires immediate intervention. Assessing and addressing peritonitis promptly is crucial to prevent further complications and ensure the client's safety. Choices A, B, and D present important findings that require attention but are not as urgent as peritonitis, which can quickly escalate and endanger the client's health.

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